Drinking 200 Proof Pain

The emotional consequences of providing emergency care

This is my column in the September/October edition of Common Sense, the magazine of the American Academy of Emergency Medicine, for which I serve as editor. The link to this issue is below. It’s a great issue, with contributions (as always) from many great physician writers.

The topic is the emotional consequences of working in the midst of suffering. This is particularly relevant given the terrible events surrounding the recent hurricanes. I feel for all of those working in rescue and recovery. This is not a thing you simply walk away from and forget.

https://issuu.com/aaeminfo/docs/cs24_septoct-vfinal/7

Drinking 200 Proof Pain

'Gunshot wound to chest, pulseless, 20 minute ETA.'

When that's the EMS report, it gets your attention. Despite the wonderful theatrics of modern medical shows, and the best efforts of real-world, sweat-drenched paramedics, those of us who have done this long enough can translate that report. For the layperson it means: 'Dead.'

I saw that last week. And the week before I saw another tragic, unexpected death in a man not much older than me. Twice I walked into a small room, looked into someone's face and said, 'I'm sorry, but he died.' Twice there was weeping and moaning, and a woman sliding to the side of the chair as someone else tried to hold her up. A woman suddenly contemplating life without a person of inestimable value to her happiness.

I have this theory about what happens to those who see such things and give such news. Let's say you send a young man or woman in the armed forces to Afghanistan. He or she is there for a year and sees combat. Or doesn't, but witnesses the consequences; victims of IED's, for instance. The young soldier treats those wounds, or prepares those bodies. They live with the constant threat of their own grave injury or death. When they return, if they come to our emergency department and say, 'I have PTSD,' we say, 'I understand.' We believe them. And why not? Who are we, who am I, to say what event or set of events is sufficient to cause nightmares, anxiety, horrible memories, paralyzing fear?

On the other hand, what if we send a physician or nurse to a civilian emergency department for 10 years, 20 years? A physician myself, I can say that while we admit that it's difficult to care for the dying, the broken, the shattered; while we admit that it's horrible to give 'the news,' we just press on. After all, we get paid well, right? And to admit the emotional consequences seems a little soft, doesn't it? I mean, we can power through can't we? It was only a dead child, it's only a hallway full of grief, it's only self-reflection and self-doubt. There are patients to see. It's only 2 a.m., or 2 p.m.. There are five or eight or 12 more hours to go!

Later, after work, sometimes for weeks or months (or years), it's the repeating loop in the middle of the night, as we ask 'what else could I have done?' It's only the question, as we kiss our families, 'what if that were my child? What if that were my spouse?' We hold them closer for a while.

So, to avoid weakness, or the general disregard of our professional organizations, we call it 'burn out.' 'I can't do this anymore,' we say, ' it's the administrators! It's the electronic medical records! It's the falling revenue! It's the drug seekers or the shift work or the patient satisfaction...' or any number of very real reasons to be frustrated and reconsider our careers. But not THE real reason.

Maybe, just maybe, it's drinking 200 proof pain and suffering for a very long time. What's the toxic threshold? What's the number of shattered humans, the number of death notifications before half of us want to quit? How much blood must we bathe in to be excused?

My theory is just this; perhaps what we call burnout is our own PTSD. Our own brain (our own soul even) saying, 'enough.' And it applies to more than physicians. It applies to nurses and to PA's and nurse practitioners. It goes for police officers, who are often the first to see the lifeless or gasping form in the savaged car, or the bloody floor of a hotel or bar. It goes for the first responders, paramedics and fire-fighters who jump into the fray fearlessly trying to snatch life from death. They 'burn out' too.

And it's OK. Because what we do, what we see, isn’t normal. Not in the way most people have normal days. It’s normal for us. We simply embrace the screams and blood and final breaths. It’s good that we can do it. It’s valuable and it saves lives and eases pain. But on a very real level, it’s terrible and life changing for us all.

So to everyone who sees and intervenes in life and death situations, I say this: You've done more good than you can ever imagine. If you tell me it hurts too much to go back, then there's no shame. Go in peace.

Because that 200-proof pain is bitter stuff. And as accustomed as we are to the taste, none of us have keep drinking it forever.